Aims: A systematized review aimed to identify the impact of basic electrocardiogram (ECG) training courses on qualified nurses. Background: ECG plays a crucial role in helping to diagnose, follow-up, and detect any abnormalities in patients' conditions. Nurses often work on the frontline in hospitals and are the ones who initially assess patients' conditions. According to the British Heart Foundation (n. d), 26% of all mortality in the UK is attributable to heart and circulatory diseases. Methodology: A comprehensive, systematized review was undertaken using the AMED, EMBASE, CINAHL, and MEDLINE databases. Thematic analysis was then used to synthesis the findings from the studies selected. Ten papers were selected following the application of inclusion and exclusion criteria. Conclusion: Basic ECG training courses were found to improve nurses' knowledge, compared to those who did not possess ECG training, the quality of care was seen better among nurses who had received ECG courses, and even patient outcomes were improved in the total number of myocardial infarction events in hospital which was decreased compared to before the intervention. Cardiac care nurses had better ECG interpretation skills than other nurses regardless if they took ECG courses or not.

Electrocardiogram (ECG) plays a crucial role in helping to diagnose, follow-up, and detect any abnormalities in a patient's condition. Nurses are usually the first to conduct an ECG and therefore need to know how to interpret them. This is because a failure to detect abnormalities means that physicians will not be notified which will affect patients' care. However, some nurses do not know exactly where to place the electrodes on the patients, and some routinely carry out an ECG without comparing the results to previous ECGs. Consequently, any complications will not be noticed as they do not possess the requisite interpretation skills.

According to the American Heart Association (AHA 2018),[1] ECG is “An ECG – abbreviated as EKG or ECG – is a test that measures the electrical activity of the heartbeat. With each beat, an electrical impulse (or “wave”) travels through the heart. This wave causes the muscle to squeeze and pump blood from the heart. A normal heartbeat on an ECG will show the timing of the top and lower chambers.”

An ECG provides an important way to diagnose myocardial infarction (MI) and other electrical pathways in the heart (AHA 2018).[1] Pelter et al.[2] stated that nurses often work on the frontline in hospitals and are usually the ones who initially assess patients. Nurses must, therefore, know how to carry out an ECG and interpret cases of MI or other cardiac problems. The ECG is the most commonly performed cardiac diagnostic procedure in the world. Approximately >100 million ECGs are recorded annually in Europe.[3] The test is, therefore, a fundamental part of all healthcare settings.[4]

According to the British Heart Foundation (BHF, 2018)[5] 26% of all deaths in the UK are attributable to heart and circulatory diseases. The main cause of a heart attack is coronary heart disease, and 188,000 hospital visits each year are due to MI. In addition, approximately 91500 people in the UK have survived a heart attack. Therefore, the British Heart Foundation (BHF, 2018) recommends diagnosing an MI by conducting an ECG which is one of the numerous diagnostic tests that can used and is both noninvasive and relatively inexpensive.

According to the National Health Services (2018),[6] an ECG can help detect the following:

Coronary heart disease – where there is insufficient blood supply to the heart due to ischemia

Arrhythmias – where heartbeats are irregular, fast, or slow

Heart attack – where the supply of blood to the heart is totally blocked

Cardiomyopathy – where the heart walls become enlarged or thickened.

A series of ECGs can be helpful in monitoring the patient's condition to keep track of any changes that might take place. An ECG is a fast, painless, and safe test.

Although other tests such as troponin are more accurate in an emergency, the ECG is still the most widely used diagnostic test for assessing patients with chest pain.[6] Therefore, it is vitally important that nurses in critical areas know how to record and interpret an ECG so that fast decision can be made.[7]

The practical use of the latest standards of electrocardiography trial conducted by Funk et al.[8] concluded that online ECG courses improve nurses' knowledge, patient outcomes, and the quality of care.

Although ECG training forms part of most undergraduate nursing programs, research has shown that there is a lack of competence among students and nurses in recognizing ECG rhythms.[9] For instance, Pourmand et al.[10] conducted a prospective study of medical students engaged in emergency medicine rotation and EM residents. They concluded that online interactive ECG training improves the ability of medical students and emergency residents to correctly recognize and interpret ECG evidence from an MI.

In research by Pelter et al.,[2] pre- and post-tests were completed by nurses to assess both the effectiveness of education materials and an easy to learn tool. The results showed that both education and an easy to learn tool improved nurses' ability to identify ST-segment Elevation MI (STEMI) criteria. These findings identify important educational opportunities for nurses working in environments where ECG interpretation is considered a standard practice.[2]

Methodology

A clinical question has to be directly related to the patients or phenomena at hand, and it builds in such a method to make an answerable question. PICO [Table 1] makes this process systematic. It plays a crucial role in building a well clinical question. It also facilitates to formulate the strategy of search by detecting the key concepts that need to be considered in the study that can answer the enquiry.[11],[12]

A comprehensive, systematized review was undertaken using the AMED, EMBASE, CINAHL, and MEDLINE databases. These were chosen because they focus on health sciences. The methodology has been chosen as it is recommended for postgraduate students' assignment.[13] The key search terms were as follows: ECG, Nurse, Education, and Knowledge, as outlined in [Table 2].

The research resulted in large potential studies and the inclusion and exclusion criteria were applied as shown in [Table 2]. Resulted in 218 potential studies as shown in [Figure 1]. Therefore, the author has read all of the abstracts that came after applying the criteria. Not all of the studies included nurses and some of the studies were not relevant even after narrowing it down. The date 2010 has been chosen in order to have the most recent guidelines for ECG from American Heart Association and British Heart Foundation. Therefore, this date has been chosen to be included in the inclusion criteria. Hierarchy of evidence has been used to help in critiquing the quality of the studies that were chosen.[14]

Study Quality Assessment Tools by the National Heart Lung and Blood Institute (NHLBI, 2014)[15] were used to critique the studies as the chosen studies conducted different designs and the NHLBI gives clear guidance for critiquing each type of study especially for pre and post-intervention studies, which is fully addressed in [Appendixes 1],[Appendixes 2],[Appendixes 3]. The sample sizes ranged from n = 14[15] to n = 686.[8] All the studies had received ethical approval. Most of the studies were from the US and the remainder were from Australia, Iran, Spain, Sweden, and China. All the studies employed a quantitative methodology. Six of the studies utilized a pre- and post-intervention design. These were the studies by Pelter et al.[2] Blakeman et al.;[16] Zhang and Hsu;[17] Forfa;[15] Preston et al.;[18] and Bazrafkan and Hemmati.[19] Of the remainder, the studies by Coll-Badell et al.,[20] Werner et al.[21] and Arslanian-Engoren et al.[22] employed an observational approach while Funk et al.[8] conducted a Randomized Clinical Trial.

Synthesis of findings/core themes

Critiquing each research paper was the first step that guided to analyze and synthesize the articles. By critiquing the chosen papers, the strengths and weaknesses were identified in each study. Therefore, that helped to analyze and synthesize the findings (Aveyard 2014, p. 137).[23] Hence, similarities and differences have been addressed in the analysis and synthesis part. Thematic analysis has been used for this approach. First, a critical summary was provided. Second, themes were identified from the main findings of each study. And then, themes have been generated. Following that, the strengths of evidence were discussed. Subsequently, themes have been named. After that, the themes were compared. Following that, close security for the themes was maintained. Finally, the result seemed to appear too neat (Aveyard 2014 p. 143-149).[23]

The core themes that emerged from the papers were as follows

Improved quality of care

Increase in nurses' knowledge

Improved patient outcomes

Cardiac Care Nurse and ECG skills.

Each of these will now be addressed in turn.

Improved quality of care

ECG training courses significantly improved the quality of care provided by nurses. Funk et al.,[8] who conducted a randomized clinical trial (crossover), concluded that ECG courses lead to better quality of care in terms of the placement of ECG leads and choosing an appropriate lead for specific groups of patients such as those who require QT interval or ST-segment monitoring. Placement on the left leg and of the V lead significantly improved after the intervention. The rate of lead placement accuracy was >90% for nurses who had undertaken the intervention, whereas the accuracy for the V lead was only 62%–65%. Regarding rhythm interpretation, there was a substantial improvement from 82% to 98% after the intervention. In addition, Funk et al.[8] observed >4000 patients' ECGs in telemetry and found that, after the intervention, there was a notable improvement in the accuracy of monitoring up to 70% which was sustained for 15 months. Although appropriateness of the use of the QT and ST segment improved, this was not statistically significant (before 56% to after 67%, P = 0.0608). However, the result was statistically significant (75% P = 0.2895) at time 3 due to the strong intraclass correlation. Pelter et al.[2] concluded that a brief ECG education course and a hand-held tool improved the accuracy of identifying STEMI from 88% pre to 95% post. Moreover, the accuracy of MI location improved along with the accuracy of identifying nonischemic MI (from 52% pre to 67% post). By contrast, the tool did not improve the accuracy of identifying left bundle brunch block (LBBB) as this was higher in the pre-intervention (59% to 47%) and early repolarization reduced from 40% to 39%. This might be due to over interpretation of LBBB and early repolarization (leading to an increase in false positives). Nevertheless, the overall comparison between the pre- and post-test educational intervention showed that the accuracy of rhythm interpretation had significantly improved by 50%.[15] Such an improvement may enhance the quality of care. Preston et al.[18] also conducted a pre–post-test to ascertain the effectiveness of atrial electrogram (AEG) programs and found that the accuracy of AEG interpretation increased from 64% pretest to 88% posttest. Moreover, after 8 weeks the percentage remained high at 89%.

Increase in nurses' knowledge

There was a significant association between undertaking ECG courses and improvements in nurses' knowledge. Funk et al.[8] analyzed 7329 knowledge test scores for 3031 qualified nurses and found that there was a significant improvement in nurses' knowledge from a mean of 49.4 and 49.2 pre-intervention to 71.0 and 70.2 post-intervention. However, the post-test result was obtained directly after the intervention; 15 months later when the test was repeated, the mean score had fallen to 59.4. Nevertheless, although the score was significantly lower than the post-test sore, it was still significantly higher than the baseline score of 49.2 (P < 0.0001). Blakeman et al.[16] also explained that nurses' knowledge and comfort regarding continuous ECG monitoring for cardiac ischemia improved after completing the educational intervention. Their knowledge level, out of a score of 9, was only 3.11 (standard deviation [SD] 1.68) pre-intervention while the mean after the intervention was 6.94 (SD 1.55). Zhang and Hsu[17] also reported that ECG education and a self-learning handbook resulted in a significant improvement in nurses' knowledge compared to pre-test. The improvement was sustained 2 weeks after the intervention and after 4 months (Z = −5.380, P < 0.01). Similarly, Bazrafkan and Hemmati[19] employed a Solomon four groups design and found there was a substantial improvement in skills and knowledge in the interpretation of cardiac arrhythmias among those nurses who had taken cardiac arrhythmia simulator courses. The significant difference between the pre- and post-intervention was at a level of P < 0.05. In addition, Coll-Badell et al.[20] found that nurses who had received ECG training courses within 5 years achieved a score that was 0.4 points higher on an average than those who did not take these course (P = 0.031). They concluded that knowledge was not associated with experience but with training. Based on questionnaires that were provided to emergency nurses, Arslanian-Engoren et al.[22] recommended that educational programs would be helpful in improving the competence level of emergency nurses and thus ensure compliance with the AHA guidelines.

Improved patient outcomes

Because ECG teaching courses improved both quality of care and nurses' knowledge, they also improved patient outcomes. For instance, Funk et al.[8] found an association between the standardization of ECG practice through ECG education and patient outcomes. The intervention was associated with a decrease in the number of MI cases during hospitalization and the proportion of MI cases declined significantly in both groups following the intervention. However, the intervention was not associated with decreased mortality rates. Having said that, nurses were able to identify the symptoms of MI (ischemia) before it was diagnosed as acute MI. Prior to the intervention; the percentage of MI in the hospital was 3.1% and 2.4%, respectively, in both groups and this decreased to 2.3% and 1.5%, respectively, after the intervention. In addition, Forfa[15] identified a correlation between nurses' knowledge and improved patient outcomes which was because the intervention improved nurses' understanding of how to interpret arrhythmias. This will also improve patient outcomes as it enables nurses to identify the most vital arrhythmias for chronic kidney disease (CKD), for example when patients experience an electrolyte imbalance.[24]

Cardiac care nurse and electrocardiogram skills

Zhang and Hsu[17] found that among emergency and ICU nurses, those who worked in cardiology units scored higher marks in the pre-test. There was no difference between the participants in terms of educational level, but cardiology nurses scored higher because they deal more frequently with ECGs monitoring. Werner et al.[21] found that neither education nor experience were associated with having better ECG skills, but coronary care unit experience was associated with having higher ECG interpretation skills.

Discussion

All the articles were quantitative studies on the efficacy of ECG training courses. Studies by Pelter et al.[2] Forfa;[15] Preston et al.,[18] and Funk et al.[8] showed that ECG training programs have a positive impact on the quality of care delivered by qualified nurses. Online teaching, classroom teaching, or a combination of both, resulted in better ECG skills.[25],[26] Therefore, these studies highlight the significance of these kinds of courses in terms of ensuring higher standards of quality of care.

Funk et al.[8] also highlighted the strong association between educational programs and positive quality of care, an increase in nurses' knowledge, and improved patient outcomes. Unlike other studies that focused on 12-lead ECGs, Funk et al.[8] addressed the significance of continuous monitoring of the ST segment and QT interval as these form part of the AHA recommendations (Rautaharju et al. 2009).[27] Although some studies tested the significance of the QT interval Rajaganeshan et al.;[28] Pickham et al.;[29] Sandau et al.,[30] and DiLibero et al.,[31] none included special strategies to convert QT monitoring knowledge into practice. The outcomes of the study by Funk et al.[8] were statistically significant and the design was an RCT crossover. It, therefore, took 6 years to finalize their outcomes, but these might beneficially inform the standardization of ECG skills among qualified nurses.

Research has shown that arrhythmias are frequently missed by staff.[32] However, the studies conducted by Pelter et al.,[2] Forfa,[15] and Funk et al.[8] concluded that ECG programs helped improve the accuracy of rhythm interpretation and decreased the likelihood of missed arrhythmia. Although the intervention improved the overall accuracy of lead placement, lead V still has a lower accuracy rate; not only in these papers but also in others.[31],[33]

Nurses seemed to be over interpreting the presence of STEMI in Pelter et al.'s[2] research. This may be because they had received a teaching intervention that may have encouraged false positives and nurses were not allowed to share their interpretation with other colleagues which is not typical in real practice. Therefore, the outcomes might not be effective. However, the overall conclusion was that ECG courses were significantly helpful in identifying the presence of STEMI and non-STEMI (NSTEMI) but not the location of infarction. The strong association between CKD and cardiac arrhythmias is because many kidney disease patients experience arrhythmia complications due to electrolytes imbalance.[24] Forfa[15] found that ECG education improved renal nurses' interpretation of arrhythmias which can improve quality of care and the early identification of arrhythmia events. However, only 14 nurses were included in the sample and the limitations of the study weaken its credibility and generality. Preston et al.[18] aimed to assess skills in atrial arrhythmia interpretation, pre- and post-test, among nurses who seemed to lack this knowledge. This is because many patients who undergo a post cardiac operation might experience atrial arrhythmia complications.[34] Thus, it is important for nurses to successfully interpret atrial arrhythmias so that they can be identified early and facilitate prompt action. Although the outcomes of Preston et al.[18] were statistically significant, they could not guarantee that the result would be sustained as they only repeated the test 8 weeks after the intervention. Recommendations by the NHS Trust (2016)[35] developed by The Society of Cardiological Science and Technology state that because the performance of 12-lead ECG requires skills in landmark placement and rhythm interpretation, their course aims to specifically improve ECG skills among staff.

In addition, the studies by Arslanian-Engoren et al.;[22] Zhang and Hsu;[17] Blakeman et al.,[16] Coll-Badell et al.,[20] Funk et al.,[8] and Bazrafkan and Hemmati[19] all concluded there is a correlation between ECG training courses and improved knowledge among nurses. The AHA also suggest that ECG programs will help to improve nurses' knowledge of ECG and Acute Coronary Syndrome guidelines.[22] However, the major issue facing studies regarding knowledge scores is that, although there may be improvements in nurses' knowledge of ECG skills, this may not be sustained in the long-term.[26] It is, therefore, recommended that nurses retake ECG courses every 5 years.[20] It has also been suggested that modern teaching methods such as online teaching and the use of simulations will have a positive impact on knowledge retention among nurses.[36] The studies by Funk et al.[8] and Bazrafkan and Hemmati[19] employed a randomization design to reduce the risk of bias and identify whether their intervention was effective.[14] By contrast, the studies by Blakeman et al.[16] and Zhang and Hsu[17] did not have a large enough sample size as their response rate was <50% which may weaken their findings.[37]

Funk et al.,[8] Forfa.,[15] and Pelter et al.[2] concluded that ECG training courses for qualified nurses were associated with improved patient outcomes. Although mortality and survival rates were not associated with ECG training courses in terms of patient outcomes, the total number of MI events in hospital decreased compared to before the intervention; this may be because nurses were able to identify signs of ischemia at an early stage due to their increased knowledge. A retrospective meta-analysis conducted by Akkerhuis et al.[38] showed that, in patients with NSTEMI, each transient ischemic event detected by monitoring increases by approximately 25% the risk of death during the 1st month of an MI event. Therefore, qualified nurses will be able to identify any ischemic event if they have ECG interpretation skills, which is likely to result in better patient outcomes. However, Bovino et al.[39] concluded that there was no association between ST segment monitoring and outcomes for patients at low risk of having MI. By contrast, if a STEMI was identified at an early phase, this would lead to better survival rates after 30 days and 1 year.[40],[41] Therefore, given that nurses are always on the frontline, this elucidates the association between ECG skilled nurses and improved patient outcomes. For instance, the management of the right ventricular infarction differs from the left ventricular infarction in terms of intravenous fluid management. Qualified ECG trained nurses will thus be able to make the right decision which results in better patient outcomes.[2],[8],[15]

Moreover, Zhang and Hsu[17] and Werner et al.[21] found that cardiac care nurses have higher ECG interpretation skills than other nurses. Both studies concluded that this was because cardiac care nurses are exposed to frequent cardiac cases involving the interpretation of arrhythmias and work with an expert cardiology team, all of which helps to improve their ECG interpretation skills. Frequent ECG interpretation based on experience is therefore associated with higher ECG skills (Hoyle et al. 2007).[42]

Strengths and limitations

The strengths of the systematized review are that it focuses on important aspects of the ECG skills required by qualified nurses. Although other studies or reviews have highlighted the significance of ECG interpretation skills, this review only focused on qualified nurses because their position on the frontline of case means they play a very important role.

The limitations of the review are that, being a novice researcher, the author's approach to the methodology in terms of research strategies, inclusion and exclusion criteria, critiquing the chosen papers, and synthesizing the themes might not be at the same level as that of an expert researcher. Furthermore, not all the chosen studies for systematized review had a high level in terms of the hierarchy of research evidence which may affect the generality of the outcomes. In addition, the author faced time constraints when conducting the review.

Conclusion

The systematized review has identified the significance of qualified nurses undertaking ECG training courses. Most studies concluded that basic ECG training courses were found to improve nurses' knowledge, compared to those who did not possess ECG training, the quality of care was seen better among nurses who had received ECG courses, and even patient outcomes was improved. In addition, although cardiac care nurses possessed ECG interpretation skills due to their experiences, the training courses nevertheless helped improve their levels of knowledge. From the review it can also be concluded that the use of different approaches in ECG training courses (online, simulation, and lectures) also improved quality of care, nurses' level of knowledge, and patient outcomes. Additional ECG training every 5 years is, therefore, recommended to maintain the quality of care and high level of knowledge among nurses. Furthermore, the findings, in conjunction with the guidelines of the AHA and NHS Trust, suggest that ECG interpretation skills have now become vital for qualified nurses. Standardized ECG interpretation skills are, therefore, recommended for all qualified nurses, especially in critical care settings.

Rautaharju PM, Surawicz B, Gettes LS, Bailey JJ, Childers R, Deal BJ, et al. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: Part IV: The ST segment, T and U waves, and the QT interval: A scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, council on clinical cardiology; the American college of cardiology foundation; and the heart rhythm society. Endorsed by the international society for computerized electrocardiology. J Am Coll Cardiol 2009;53:982-91.